Elsevier

The Lancet

Volume 351, Issue 9119, 20 June 1998, Pages 1833-1839
The Lancet

Articles
Spectrum of AIDS-associated malignant disorders

https://doi.org/10.1016/S0140-6736(97)09028-4Get rights and content

Summary

Background

To clarify which types of cancer result from AIDS, we compared the cancer experiences of people with AIDS with those of the general population by matching population-based cancer and AIDS registries in the USA and Puerto Rico.

Methods

We used a probabilistic matching algorithm to compare names, birth dates, and, where available, social-security numbers of 98336 people with AIDS and 1125098 people with cancer aged less than 70 years. We defined AIDS-related cancers as those with both significantly raised incidence post-AIDS and increasing prevalence from 5 years pre-AIDS to 2 years post-AIDS.

Findings

Among people with AIDS, we found 7028 cases of Kaposi's sarcoma (KS), 1793 of non-Hodgkin lymphoma (NHL), and 712 other cases of histologically defined cancer. Incidence rates among people with AIDS were increased 310-fold for KS, 113-fold for NHL, and 1·9-fold (95% Cl 1·5–2·3) for other cancers. Of 38 malignant disorders other than KS and NHL, only angiosarcoma (36·7-fold), Hodgkin's disease (7·6-fold), multiple myeloma (4·5-fold), brain cancer (3·5-fold), and seminoma (2·9-fold) were raised and increasing significantly (p<0·02) from the pre-AIDS to the post-AIDS period.

Interpretation

Interpretation is complicated by screening and shared risk factors, such as sexual behaviour and cigarette smoking. However, our data indicate that AIDS leads to a significantly increased risk of Hodgkin's disease, multiple myeloma, brain cancer, and seminoma. Immunological failure to control herpes or other viral infections may contribute to these malignant diseases.

Introduction

Cancer risk is increased with most types of immune deficiency, including congenital disorders and iatrogenic treatments to prevent allograft rejection.1 With AIDS, cancer risk is extraordinarily high and has an unusual spectrum.1, 2 An understanding of this spectrum may clarify the interplay between immunity, viruses, and other carcinogenic agents, and indirect carcinogenic mechanisms, including regulators of mitosis and growth. Kaposi's sarcoma (KS) and high-grade B-cell non-Hodgkin lymphoma (NHL) are the prototypical AIDS-defining malignant diseases, with 2419 and 1030 cases, respectively, reported to the Centers for Disease Control and Prevention during 1996.3 However, many other neoplasms have been reported among people with AIDS. Causal relations between AIDS and these other cancers have not been defined because of potential confounding by sexual and other lifestyle variables, and because of ascertainment bias from the intensive diagnostic scrutiny of people with AIDS. To clarify these issues we established the AIDS-Cancer Match Registry, and developed methods to examine the relation between AIDS—defined as the initial life-threatening opportunistic illness—and the prevalence and incidence of 38 histologically defined malignant disorders reported to population-based cancer registries in the USA and Puerto Rico.

Section snippets

Matching and linkage of AIDS and cancer data

The National Cancer Institute collaborated with the population-based cancer registries and AIDS registries in Puerto Rico and in seven regions in the USA (New Jersey, Florida, Atlanta, San Francisco, Los Angeles, San Diego, and Sacramento). Records were linked by computer with a probabilistic algorithm that matched social-security numbers in those registries in which they were available (San Francisco and Los Angeles).4 For the other regions, the matching algorithm incorporated two critical

Results

The AIDS-Cancer Match Registry compared the records of 98 336 people with AIDS with the records of 1 125 098 people with cancer. For the cohort analysis, there were 40 733 post-AIDS person-years at risk, including 26 398 person-years (65%) for white or Hispanic homosexual men, 3336 (8%) for black homosexual men, 7386 (18%) for other males, and 3612 (9%) for females.

Discussion

This study expands the known spectrum of AIDS-related malignant disorders and also shows that most cancers are not related to immunodeficiency. The experiences of patients with AIDS and other immunodeficiencies help elucidate the cause of some tumours. Nearly all immunodeficiency states have in common an extraordinary risk of NHL that roughly parallels the intensity of immune stimulation and the severity of immune deficiency. For kidney-transplant recipients, NHL risk is increased most within

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